EMS Medicine Live!

Welcome

Seventh EMS Webinar

EMS Medicine Live!

• EML’s Mission – Community & Academic EMS Physician Education

• Information Sharing • Board Preparation

– Group involvement • See and meet your peers • Involve your unique experiences and skills

EMS Medicine Live! Course Directors

Christian Knutsen, MD, MPH

Derek Cooney, MD

Brian Clemency, DO

EMS Medicine Live

• Zoom – During presentation

• Everyone will be muted • Chat questions to EMS Medicine Live • Raise hand virtually in chat window

– Recording • Upstate will record and post conferences online • You can record at your site also

EMS Medicine Live

• Zoom – Questions

• Questions at the end – Unmute yourself to ask a question or – Message EMS Medicine Live if you have a question and I’ll ask for questions in

order.

EMS Medicine Live

• Zoom – Technical Problems?

• Message me if you have a suggestion. • If you have a serious problem, email knutsenc@upstate.edu

EMS Medicine Live

Rescue Task Force Harry Wallus, DO, MPH, FACEP

– Residency: SUNY Upstate – EMS Fellowship: SUNY Upstate – EMS Medical Director, Portsmouth Regional Hospital – Seacoast Emergency Response Team Physician

RTFs: The Evolution of EMS in Immediate Threat Scenarios HARRY J. WALLUS, DO, MPH, FACEP

EMS MEDICAL DIRECTOR

SERT PHYSICIAN

PORTSMOUTH REGIONAL HOSPITAL

Objectives

Discuss the traditional role of EMS in immediate threat scenarios Identify the impetus for change Identify and discuss terminology Discuss the difference between tactical medics/physicians and RTFs Highlight interventions and thought processes different in this

environment versus traditional EMS What are we doing in NH? Review a recent active shooter drill carried out here in NH

Traditional Role of EMS in Active Shooter/Immediate Threat

Scenarios Victims/patients delivered to you or egress on their own Triage and transport accordingly Stage away from the scene in the “cold zone” EMS kept “away from the fight” until hot zone became a cold zone

Tactical Medicine

Tactical medicine has been a mainstay of military operations since the days of Napoleon

Switched to civilian SWAT teams after a seminal event at the University of Texas at Austin where on August 1, 1966 a sniper (Charles Whitman) shot and killed 15 people while wounding 31 others

LAPD and LA County Sheriff’s Department were among the first to develop tactical teams

Prior to 1989, medical care to SWAT teams came from regular civilian EMS staged at safe locations removed from areas of operation

After the Gulf War, the concept of getting medical care “close to the fight” was realized and implemented during Operation Iraqi Freedom

This translated to the civilian environment as well Evolved from tactical emergency medical support, to tactical EMS, and

now tactical medicine

Lessons Learned in the Civilian Arena

Columbine in 1999 The numbers: Over 100 incidents and according to FEMA 250 people killed

between 2000 and 2012 with a drastic rise since 2008. Sandy Hook : “maximizing survival requires an updated and

integrated system that can achieve multiple objectives simultaneously”

Dept of Homeland Security: “in order to maximize lives saved, there is a need to get life-saving medical attention to victims quickly. In previous active shooter incidents, the focus has been exclusively on law enforcement neutralizing the threat”

EMS in the Warm Zone

Active Shooter: An individual or individuals actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims.

Ballistic Protective Equipment: Ballistic protective gear, including body armor, for the head and body; i.e., vests, gloves, knee pads, helmets, and shields.

Casualty Collection Point (CCP): A location that is used for the assembly, triage (sorting), medical stabilization, and subsequent evacuation of casualties. It may be an intermediary point before formal triage.

Cleared: An area has been searched and does not pose a threat – no perpetrator present.

Definitions

Cold Zone: i) Area where no significant danger or threat can be reasonably anticipated. ii) Area where triage and treatment of patients would occur, additional resources would be staged, and command functions carried out.

Concealment: A structure that hides a person’s exact location but can be penetrated by ballistic weapons (e.g. a sheetrock wall).

Contact Team: The first responding officers/security personnel who go directly to the ongoing threat, make contact as soon as possible, and neutralize the threat, in order to minimize injuries and lives lost.

Cover: An area generally impenetrable to ballistic weapons, such as concrete wall. Something that prevents a responder from being observed by the perpetrator AND provides direct protection from the hazard/threat. i)

Definitions

Hot Zone: i) Area wherein a direct and immediate life threat exists. ii) Depends upon current circumstances and is subjective. iii) Area is dynamic and may change frequently depending upon the situation.

Incident Command: A management system designed to enable effective and efficient domestic incident management by integrating a combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure, designed to enable effective and efficient domestic incident management.

Incident Command Post: The field location where the primary functions of Incident Command are performed.

Definitions

Point-of-Wound Care: The physical location (building or otherwise) where patient care is initiated at or near to where the victim was injured.

Rescue Task Force (RTF): A team or set of teams deployed to provide point of woundcare to victims where there is an on-going ballistic or explosive threat. These teams treat, stabilize, and remove the injured while wearing Ballistic Protective Equipment in a rapid manner under the protection of law enforcement. This response can be deployed to work in, but not limited to, the following: i) Active shooter in a school, business, mall, health care facility, conference, special event, etc. ii) Any other scene that is, or has, the possibility of an on-going ballistic or explosive threat.

Definitions

Secured: An area has been searched and is now under direct Law Enforcement control.

Soft Target: A person or thing that is relatively unprotected or vulnerable, especially to attack.

Tactical Emergency Casualty Care (TECC): TECC guidelines are a set of best practice recommendations for casualty management during high threat civilian tactical and rescue operations. Based upon the principles of Tactical Combat Casualty Care (TCCC), TECC guidelines account for differences in the civilian environment, resources allocation, patient population, and scope of practice. The applications of the TECC guidelines for civilian Fire/EMS medical operations are far reaching, beyond just the traditional application in tactical and Law Enforcement operations.

Tactical Medic/Physician vs RTF

My role on SERT

The role of the rescue task force team responder

What do we have in common?

TECC – Tactical Emergency Combat Care

TCCC is the military version Many lessons learned from the wars in Iraq and Afghanistan Movement to make applicable to the civilian environment Change in mindset from traditional prehospital medicine

Introduction

The goals of Tactical Emergency Casualty Care (TECC) are:

1. Save preventable deaths 2. Prevent additional casualties 3. Rapid EMS Trauma Assessment 4. Rapid treatment of life threats

Bleeding before breathing 5. Timely evacuation

Introduction

This approach recognizes a particularly important principle: To perform the correct intervention at the correct time in the continuum

of Tactical Care

A medically correct intervention performed at the wrong time in potentially hostile environment may lead to further casualties

Combat Deaths

KIA: 31% Penetrating head trauma KIA: 25% Surgically uncorrectable torso trauma KIA: 10% Potentially surgically correctable trauma KIA: 9% Hemorrhage from extremity wounds KIA: 7% Mutilating blast trauma KIA: 5% Tension pneumothorax KIA: 1% Airway problems 12% Mostly from infections and complications of shock

Preventable Causes of Combat Related Deaths

60% Hemorrhage from extremity wounds 33% Tension pneumothorax 6% Airway obstruction e.g., maxillofacial trauma

• Data is extrapolated from Vietnam to

present day Iraq and Afghanistan

Stages of Care 3 Distinct Phases

Care in potentially hostile environment.

Tactical Field Care Tactical Casualty Evacuation Care

Care in Potentially Hostile Environment

EMS shall not be armed Available medical equipment is limited to that carried by the

medic or first responder Tourniquets

Chest Seals and 10 g catheters for chest decompression

Trauma Dressings

Nasal Airways

Hemostatic dressings

Space blankets

Casualty tags

Tactical Field Care

“Tactical Field Care” is the care rendered by the medic once it has been determined by Police that the scene is no longer under direct threat, “Warm Zone Entry”

Available medical equipment still limited to that carried into the field by medical personnel

Time to evacuation may vary considerably

Tactical EVAC

“Tactical Evacuation” is the rapid evacuation of a casualty using Megamover, Skedds or Drags

Additional medical personnel and equipment will be staged per Incident Command for additional casualty management and rapid transport to appropriate hospital destination

Care in Hostile Environment

Minimal attention to airway at this point because of need to evacuate the casualty quickly

Control of hemorrhage is essential since injury to a major vessel can result in hypovolemic shock in a short time frame

Remember the “Average” person can exsanguinate in 3-5 minutes with a major vessel injury i.e. Femoral Artery Disruption

Massive Hemorrhage

Tourniquets

Care in Hostile Environment

“Control Bleeding” The tourniquet should be placed on the extremity 2-3

inches, above the injury as soon as possible, ignoring the clothing

Combat Application Tourniquet (CAT)

WINDLASS

OMNI TAPE BAND WINDLASS STRAP

Key Points

Airway management beyond placing a nasopharyngeal is best deferred until the casualty reaches treatment area

Stop any life threatening hemorrhage with a commercially available tourniquet (CAT)

Apply tourniquet for any total or partial amputation regardless of bleeding

Consider hemostatic dressings, and trauma pressure dressing

Reassure the casualty

Tactical Emergency Casualty Care Initial Casualty Assessment

Bleeding control before breathing

Nasal airways, no advanced airways

Place in a position to maintain open airway

No CPR/rescue breathing

Rapid treatment and evacuation

Ongoing Assessment, Treatment Area Airway- advanced PRN

Breathing- o2- assisted as needed

Circulation- IV/IO access, fluid resuscitation

Tactical Emergency Casualty Care

Open the airway with a chin-lift If unconscious and spontaneously

breathing, insert a nasopharyngeal airway

Place the casualty in the recovery position

Nasopharyngeal Airway

Tactical Emergency Casualty Care :Breathing Traumatic chest wall defects should be closed quickly with an

occlusive dressing without regard to venting one side of the dressing

Also may use an Asherman Chest Seal or Sam Chest Seal Allow casualty to assume position that best protects the airway,

including sitting up

Place unconscious casualty in the recovery position

"Asherman Chest Seal"

Sam Chest Seal

Needle Chest Decompression

Tactical Emergency Casualty Care :Circulation

Any bleeding site not previously controlled should now be aggressively addressed

Only the absolute minimum of clothing should be removed, although a thorough search for additional injuries must be performed

Hemostatic Dressing Apply directly to bleeding site and hold in place 2 minutes,

casualty assist if possible If dressing is not effective in stopping bleeding after 4

minutes, remove original and apply a new dressing Additional dressings cannot be applied over ineffective

dressing Pack wound with gauze (enough to fill cavity) Apply a battle dressing/bandage to secure hemostatic

dressing in place If bleeding controlled, do not remove dressing

Hemostatic Dressing

Tactical Emergency Casualty Care :IV Fluids FIRST, STOP THE BLEEDING!

Deferred until evacuated to treatment area IV access should be obtained using a single 14-16 gauge

catheter because of the ease of starting. Rapidly consider I/O access

IV fluids be administered in amounts enough to maintain systolic B/P > 90 mmHg with 0.9 NS

Tactical Emergency Casualty Care

:Secondary Injuries Focus of life threats Secondary injuries deferred until after evacuation to treatment area Continually reevaluate casualties for changes in condition while

maintaining situational awareness Consider Emergency Airway

Tactical EVAC At some point in the operation the casualty will be

evacuated Time to evacuation may be quite variable from minutes to

hours A MASS CASUALTY EVENT may exceed the capabilities of the

medic

Tactical EVAC

• Ambulate before carry when possible • Rapid evacuation non-ambulatory casualties-Mega Mover, Skedds, Drags

Documentation of Care

• Document clinical assessments, treatments rendered, and changes in the casualty’s status in accordance with local protocol.

• Consider implementing a casualty care card that can be quickly and easily completed by non-medical first responders.

• Forward this information with the casualty to the next level of care.

Summary

Casualties will die from preventable deaths unless proper life-saving steps are taken as soon practical, once the Police determine that the scene is no longer under direct threat • 60% Hemorrhage • 33% Tension Pneumo • 6% Airway Obstruction This is the group MEDICS can help the most.

What does a Rescue Task Force look like?

Typically it is a 1:1 or a 2:1 LE to EMS ratio Ballistic protection in the form of vests (rated I-IV) and helmets First 2 officers in usually clear and you follow behind Security is provided as you move through the area providing TECC

for maximum number of patients for most benefit (typically supplies for 6-8 victims)

Do not forget to anticipate pediatric patients Evac becomes the focus when you cannot continue forward

progress or have exhausted your supplies. Essential to train with LE to figure out what strategy works best for

moving and switching up teams.

Bigger Picture

What are some issues, based on experience, you think need to be addressed to start off?

What unique scenarios might we face here in NH? Commonly encountered barriers to implementation

What have/are we doing here in NH?

Stake holder meetings Formulation of a best practices document (vs protocol) Derry Fire and Derry PD

Examples of successes?

Boston Marathon Bombing

Recent Active Shooter Drill in Portsmouth, NH

Drill involved multiple local police and fire agencies, emergency management, homeland security, FBI, regional SWAT (SERT) and state police SWAT, EOD

1000 hrs reports of shots fired at the high school. Callers also reporting sounds of explosions and can see/smell smoke

1005 first LE responding units arrived on scene Incident command was set up with senior LE and FD officials on duty.

SWAT activated. Casualty collection point established approximately 150-200 yards from

the high school Communications through forward operations to command identify

multiple victims corroborating 911 calls Hospital is made aware and code White initiated

Active Shooter Continued

Approach initially with operators in the BearCat who deploy SERT medic deploys with second wave of operators I am stationed in the BearCat just outside the high school Casualties are brought to the BearCat and evacuated as there are

reports of multiple active shooters 911 now receives calls reporting multiple gun shots fired at the

middle school in addition to reports of explosions State Police SWAT is now redirected to the Middle School. SERT

continues operations at the high school. Fire sets up a second command post at the Middle School.

Active Shooter Take Home

Awaiting official AAP I quickly ran out of supplies in the back of the Cat Some team members treated victims with their Med Kits Extraction limitations with real threat – feasibility of ambulances

versus Cat Timing first call to intervention with Reds and Yellows Highlights need for RTFs EMS and the hospital actually had a steady, slow pace of patients

Getting ready to deploy from rally point

Incident Command

In the Cat with EOD observing an IED

EOD tools

PFD addressing “fire as a weapon” with active shooter still at large

Review

Evolving role of EMS in immediate threat scenarios TECC – change in tactics and mindset from traditional prehospital

medicine Difference between “traditional” tactical medics and docs versus

rescue task force teams Cooperation and collaboration amongst agencies is essential

Questions?

EMS Medicine Live

• Thank you to Dr. Wallus

• Upcoming EML – August: TBA (Looking For Speaker and Topic) – September: Jeremy Cushman, “The Brewer Street Incident” – October: TBA – November: Michael Dailey, EMS and End of Life Issues – December: TBA